{"id":10919,"date":"2025-02-01T11:36:46","date_gmt":"2025-02-01T08:06:46","guid":{"rendered":"https:\/\/www.kishmedipharm.com\/?page_id=10919"},"modified":"2025-08-25T08:10:34","modified_gmt":"2025-08-25T04:40:34","slug":"drug-side-report-form","status":"publish","type":"page","link":"https:\/\/www.kishmedipharm.com\/en\/drug-side-report-form\/","title":{"rendered":"Drug Adverse Reaction Report Form"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_10\" ><label class='gfield_label gform-field-label' for='input_1_10'>First and last name<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_1_10' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_3\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_3\" ><label class='gfield_label gform-field-label' for='input_1_3'>Contact phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_1_3' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_4\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_4\" ><label class='gfield_label gform-field-label' for='input_1_4'>date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_4' id='input_1_4' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_4_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_4_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_4' class='gform_hidden' value='https:\/\/www.kishmedipharm.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_1_6\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_6\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Reporter<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_6'><div class='gchoice gchoice_1_6_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.1' type='checkbox'  value='\u06a9\u0627\u062f\u0631 \u062f\u0631\u0645\u0627\u0646'  id='choice_1_6_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_6_1' id='label_1_6_1' class='gform-field-label gform-field-label--type-inline'>Treatment staff<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_6_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.2' type='checkbox'  value='\u0628\u06cc\u0645\u0627\u0631'  id='choice_1_6_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_6_2' id='label_1_6_2' class='gform-field-label gform-field-label--type-inline'>Patient<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_6_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.3' type='checkbox'  value='\u0647\u0645\u0631\u0627\u0647 \u0628\u06cc\u0645\u0627\u0631'  id='choice_1_6_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_6_3' id='label_1_6_3' class='gform-field-label gform-field-label--type-inline'>Patient companion<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_9\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_9\" ><label class='gfield_label gform-field-label' for='input_1_9'>Address<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_1_9' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_12\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_12\" ><h3 class=\"gsection_title\">1. Patient profile<\/h3><\/div><div id=\"field_1_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_13\" ><label class='gfield_label gform-field-label' for='input_1_13'>First and last name<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_1_13' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_14\" ><label class='gfield_label gform-field-label' for='input_1_14'>Age<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_1_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_15\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_15\" ><label class='gfield_label gform-field-label' for='input_1_15'>Weight (kg)<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_1_15' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_16\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_16\" ><label class='gfield_label gform-field-label' for='input_1_16'>Telephone<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_1_16' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_17\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_17\" ><legend class='gfield_label gform-field-label' >Gender<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_17'>\n\t\t\t<div class='gchoice gchoice_1_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='\u0645\u0630\u06a9\u0631'  id='choice_1_17_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_17_0' id='label_1_17_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='\u0645\u0648\u0646\u062b'  id='choice_1_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_17_1' id='label_1_17_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_17_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='\u0633\u0627\u06cc\u0631'  id='choice_1_17_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_17_2' id='label_1_17_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_18\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_18\" ><legend class='gfield_label gform-field-label' >Pregnant<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_18'>\n\t\t\t<div class='gchoice gchoice_1_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='\u0628\u0644\u0647'  id='choice_1_18_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_18_0' id='label_1_18_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='\u062e\u06cc\u0631'  id='choice_1_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_18_1' id='label_1_18_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_19\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_19\" ><legend class='gfield_label gform-field-label' >Lactating<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_19'>\n\t\t\t<div class='gchoice gchoice_1_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='\u0628\u0644\u0647'  id='choice_1_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_19_0' id='label_1_19_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='\u062e\u06cc\u0631'  id='choice_1_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_19_1' id='label_1_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_20\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_20\" ><label class='gfield_label gform-field-label' for='input_1_20'>Address<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_1_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_21\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_21\" ><h3 class=\"gsection_title\">2. Type of drug side effect observed and therapeutic measures taken<\/h3><\/div><div id=\"field_1_22\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_22\" ><label class='gfield_label gform-field-label' for='input_1_22'>Description<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_22' id='input_1_22' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_23\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_23\" ><h3 class=\"gsection_title\">3. Date of onset of drug reaction<\/h3><\/div><div id=\"field_1_24\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_24\" ><label class='gfield_label gform-field-label' for='input_1_24'>date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_24' id='input_1_24' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_24_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_24_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_24' class='gform_hidden' value='https:\/\/www.kishmedipharm.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_25\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_25\" ><label class='gfield_label gform-field-label' for='input_1_25'>Description<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_25' id='input_1_25' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_26\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_26\" ><h3 class=\"gsection_title\">4. How long has the condition lasted?<\/h3><\/div><div id=\"field_1_27\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_27\" ><label class='gfield_label gform-field-label' for='input_1_27'>Description<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_27' id='input_1_27' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_28\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_28\" ><h3 class=\"gsection_title\">5. Patient history: (allergies, hereditary diseases, enzyme deficiencies, current diseases, addictions, etc.)<\/h3><\/div><div id=\"field_1_29\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_29\" ><label class='gfield_label gform-field-label' for='input_1_29'>Description<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_29' id='input_1_29' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_30\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_30\" ><h3 class=\"gsection_title\">6. History of any past drug side effects for the patient<\/h3><\/div><div id=\"field_1_31\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_31\" ><label class='gfield_label gform-field-label' for='input_1_31'>Description<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_31' id='input_1_31' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_32\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_32\" ><h3 class=\"gsection_title\">7. Has the observed side effect decreased after stopping the medication?<\/h3><\/div><fieldset id=\"field_1_33\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_33\" ><legend class='gfield_label gform-field-label' >Answer<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_33'>\n\t\t\t<div class='gchoice gchoice_1_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='\u0628\u0644\u0647'  id='choice_1_33_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_33_0' id='label_1_33_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='\u062e\u06cc\u0631'  id='choice_1_33_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_33_1' id='label_1_33_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_33_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='\u0646\u0645\u06cc\u062f\u0627\u0646\u0645\u060c \u062f\u0627\u0631\u0648 \u0642\u0637\u0639 \u0646\u0634\u062f\u0647 \u0627\u0633\u062a'  id='choice_1_33_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_33_2' id='label_1_33_2' class='gform-field-label gform-field-label--type-inline'>I don't know, the medication hasn't been discontinued.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_33_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='\u0646\u0645\u06cc\u062f\u0627\u0646\u0645\u060c \u062f\u0627\u0631\u0648 \u0645\u062c\u062f\u062f\u0627 \u062a\u062c\u0648\u06cc\u0632 \u0646\u0634\u062f\u0647 \u0627\u0633\u062a'  id='choice_1_33_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_33_3' id='label_1_33_3' class='gform-field-label gform-field-label--type-inline'>I don't know, the medication hasn't been re-prescribed.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_34\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_34\" ><h3 class=\"gsection_title\">8. Has the condition reappeared after repeated use of the medication?<\/h3><\/div><fieldset id=\"field_1_35\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_35\" ><legend class='gfield_label gform-field-label' >Answer<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_35'>\n\t\t\t<div class='gchoice gchoice_1_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='\u0628\u0644\u0647'  id='choice_1_35_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_35_0' id='label_1_35_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='\u062e\u06cc\u0631'  id='choice_1_35_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_35_1' id='label_1_35_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_35_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='\u0646\u0645\u06cc\u062f\u0627\u0646\u0645\u060c \u062f\u0627\u0631\u0648 \u0642\u0637\u0639 \u0646\u0634\u062f\u0647 \u0627\u0633\u062a'  id='choice_1_35_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_35_2' id='label_1_35_2' class='gform-field-label gform-field-label--type-inline'>I don't know, the medication hasn't been discontinued.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_35_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='\u0646\u0645\u06cc\u062f\u0627\u0646\u0645\u060c \u062f\u0627\u0631\u0648 \u0645\u062c\u062f\u062f\u0627 \u062a\u062c\u0648\u06cc\u0632 \u0646\u0634\u062f\u0647 \u0627\u0633\u062a'  id='choice_1_35_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_35_3' id='label_1_35_3' class='gform-field-label gform-field-label--type-inline'>I don't know, the medication hasn't been re-prescribed.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_36\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_36\" ><h3 class=\"gsection_title\">9. Finally, a drug side effect<\/h3><\/div><fieldset id=\"field_1_37\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_37\" ><legend class='gfield_label gform-field-label' >Answer<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_37'>\n\t\t\t<div class='gchoice gchoice_1_37_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='\u0628\u0647\u0628\u0648\u062f\u06cc'  id='choice_1_37_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_37_0' id='label_1_37_0' class='gform-field-label gform-field-label--type-inline'>Recovery<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_37_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='\u0639\u062f\u0645 \u0628\u0647\u0628\u0648\u062f\u06cc'  id='choice_1_37_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_37_1' id='label_1_37_1' class='gform-field-label gform-field-label--type-inline'>Lack of improvement<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_37_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='\u0646\u0642\u0635 \u0639\u0636\u0648'  id='choice_1_37_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_37_2' id='label_1_37_2' class='gform-field-label gform-field-label--type-inline'>Defect<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_37_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='\u0645\u0631\u06af'  id='choice_1_37_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_37_3' id='label_1_37_3' class='gform-field-label gform-field-label--type-inline'>Death<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_37_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='\u0633\u0627\u06cc\u0631'  id='choice_1_37_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_37_4' id='label_1_37_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_38\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_38\" ><h3 class=\"gsection_title\">10. Has a medication complication led to the patient being hospitalized?<\/h3><\/div><fieldset id=\"field_1_39\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_39\" ><legend class='gfield_label gform-field-label' >Answer<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_39'>\n\t\t\t<div class='gchoice gchoice_1_39_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='\u0628\u0644\u0647'  id='choice_1_39_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_39_0' id='label_1_39_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_39_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='\u062e\u06cc\u0631'  id='choice_1_39_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_39_1' id='label_1_39_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_40\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_40\" ><h3 class=\"gsection_title\">11. Paraclinical drug findings related to the observed complication<\/h3><\/div><div id=\"field_1_41\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_41\" ><label class='gfield_label gform-field-label' for='input_1_41'>Description<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_41' id='input_1_41' class='textarea large'  aria-describedby=\"gfield_description_1_41\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_1_41'>The results of relevant paraclinical tests (including: blood test results, types of CT scans, MRI, endoscopy, etc.) should be mentioned if available.<\/div><\/div><div id=\"field_1_42\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_42\" ><h3 class=\"gsection_title\">12. Drugs suspected of causing side effects<\/h3><div class='gsection_description' id='gfield_description_1_42'>Note: The meaning of pharmaceutical strength is the amount of active ingredient in the dosage form used. (For example: 50 mg ampoule, 100 mg tablet, etc.) <\/div><\/div><div id=\"field_1_43\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_43\" ><label class='gfield_label gform-field-label' for='input_1_43'>Drug name<\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_1_43' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_44\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_44\" ><label class='gfield_label gform-field-label' for='input_1_44'>Pharmaceutical form and strength<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_1_44' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_45\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_45\" ><label class='gfield_label gform-field-label' for='input_1_45'>Daily dosage<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_1_45' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_46\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_46\" ><label class='gfield_label gform-field-label' for='input_1_46'>Way of consumption<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_1_46' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_47\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_47\" ><label class='gfield_label gform-field-label' for='input_1_47'>Usage<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_1_47' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_48\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_48\" ><label class='gfield_label gform-field-label' for='input_1_48'>Start date of use<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_1_48' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_49\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_49\" ><label class='gfield_label gform-field-label' for='input_1_49'>Expiration date<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_1_49' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_50\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_50\" ><label class='gfield_label gform-field-label' for='input_1_50'>Manufacturing serial number<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_1_50' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_51\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_51\" ><label class='gfield_label gform-field-label' for='input_1_51'>Manufacturer<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_1_51' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_52\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_52\" ><h3 class=\"gsection_title\">13. Other medications the patient was taking at the time of the complication<\/h3><div class='gsection_description' id='gfield_description_1_52'>Note: The meaning of pharmaceutical strength is the amount of active ingredient in the dosage form used. (For example: 50 mg ampoule, 100 mg tablet, etc.) <\/div><\/div><div id=\"field_1_53\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_53\" ><label class='gfield_label gform-field-label' for='input_1_53'>Drug name<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_1_53' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_54\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_54\" ><label class='gfield_label gform-field-label' for='input_1_54'>Pharmaceutical form and strength<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_1_54' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_55\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_55\" ><label class='gfield_label gform-field-label' for='input_1_55'>Daily dosage<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_1_55' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_56\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_56\" ><label class='gfield_label gform-field-label' for='input_1_56'>Way of consumption<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_1_56' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_57\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_57\" ><label class='gfield_label gform-field-label' for='input_1_57'>Usage<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_1_57' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_58\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_58\" ><label class='gfield_label gform-field-label' for='input_1_58'>Start date of use<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_1_58' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_59\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_59\" ><label class='gfield_label gform-field-label' for='input_1_59'>Expiration date<\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_1_59' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_60\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_60\" ><label class='gfield_label gform-field-label' for='input_1_60'>Manufacturing serial number<\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_1_60' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_61\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_61\" ><label class='gfield_label gform-field-label' for='input_1_61'>Manufacturer<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_1_61' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_62\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_62\" ><h3 class=\"gsection_title\">Other related explanations<\/h3><\/div><div id=\"field_1_63\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_63\" ><label class='gfield_label gform-field-label' for='input_1_63'>Description<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_63' id='input_1_63' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_65\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_65\" ><label class='gfield_label gform-field-label' for='input_1_65'>Upload image<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='5242880' \/><input name='input_65' id='input_1_65' type='file' class='large' aria-describedby=\"gfield_upload_rules_1_65\" onchange='javascript:gformValidateFileSize( this, 5242880 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_65'>\u0627\u0646\u0648\u0627\u0639 \u0641\u0627\u06cc\u0644 \u0647\u0627\u06cc \u0645\u062c\u0627\u0632 : jpg, pdf, png, gif, btm, jpeg, \u062d\u062f\u0627\u06a9\u062b\u0631 \u0627\u0646\u062f\u0627\u0632\u0647 \u0641\u0627\u06cc\u0644: 5 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_1_65'><\/div><\/div><\/div><div id=\"field_1_66\" class=\"gfield gfield--type-captcha gfield--input-type-captcha field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_66\" ><label class='gfield_label gform-field-label' for='input_1_66'>Security code<\/label><div id='input_1_66' class='ginput_container ginput_recaptcha' data-sitekey='6LdGoMkqAAAAANsDWU3O4gd1SD2d7AZ8sq6Jnkjx'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/div><div id=\"field_1_67\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_67\" ><label class='gfield_label gform-field-label' for='input_1_67'>Phone<\/label><div class='ginput_container'><input name='input_67' id='input_1_67' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_1_67'>\u0627\u06cc\u0646 \u0641\u06cc\u0644\u062f \u0628\u0631\u0627\u06cc \u0647\u062f\u0641 \u0627\u0639\u062a\u0628\u0627\u0631 \u0633\u0646\u062c\u06cc \u0627\u0633\u062a \u0648 \u0628\u0627\u06cc\u062f \u0628\u062f\u0648\u0646 \u062a\u063a\u06cc\u06cc\u0631 \u0628\u0627\u0642\u06cc \u0628\u0645\u0627\u0646\u062f .<\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' value='Information recording'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_1' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_1' id='gform_theme_1' value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_1' id='gform_style_settings_1' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' value='WyJ7XCI2LjFcIjpcImIyMTI3NmIwNmU5ZjYwOGE5MWExZWVlNTc5MzU3NzBlXCIsXCI2LjJcIjpcIjJjMGU5NTliYjdlODZlYjdkNDY2ZjFlNjhhMmNkZjQ5XCIsXCI2LjNcIjpcIjRmMWUyMGFlZTkxMzA0Mzc0YjcwMjdlY2RiZjY1OWZhXCIsXCIxN1wiOltcIjcxYTk3ZTdiMGM5ZWM2ODI2NDA0NGExNmJlODBkMjM3XCIsXCI1YjQ1ZTRmMGM1YWJiNTQzNTdkMzdiZGY0YzE3MGNmMlwiLFwiODhhNjQwYWViZjhiMDIzYTJjZTA4ZmMxM2Y4M2E2ZDVcIl0sXCIxOFwiOltcIjZjYzdlNjA4MTBiMDQxM2EwYjNjZGM0M2IwMWRmMTJiXCIsXCJkMDVlZTgxYmU4NTAwMmEwOGM4MWExNDQyYmNmMTg4MVwiXSxcIjE5XCI6W1wiNmNjN2U2MDgxMGIwNDEzYTBiM2NkYzQzYjAxZGYxMmJcIixcImQwNWVlODFiZTg1MDAyYTA4YzgxYTE0NDJiY2YxODgxXCJdLFwiMzNcIjpbXCI2Y2M3ZTYwODEwYjA0MTNhMGIzY2RjNDNiMDFkZjEyYlwiLFwiZDA1ZWU4MWJlODUwMDJhMDhjODFhMTQ0MmJjZjE4ODFcIixcIjM1MDMyZjg1OTMyNjhkMWJhMWFhMTVhNzY1MDRlYjNlXCIsXCI0YzJhMGIxMDBiMDE1MzNmMTczNTgzMmRiYTU3MjgwMlwiXSxcIjM1XCI6W1wiNmNjN2U2MDgxMGIwNDEzYTBiM2NkYzQzYjAxZGYxMmJcIixcImQwNWVlODFiZTg1MDAyYTA4YzgxYTE0NDJiY2YxODgxXCIsXCIzNTAzMmY4NTkzMjY4ZDFiYTFhYTE1YTc2NTA0ZWIzZVwiLFwiNGMyYTBiMTAwYjAxNTMzZjE3MzU4MzJkYmE1NzI4MDJcIl0sXCIzN1wiOltcIjNjMmQ5NTk3NDFlM2M4ZWYwMGM2ZDUyOTc3MGZmN2Q2XCIsXCJlZDQ3ODRkOTA5NGI4ZDJkMjA2NDcxZWE3MjhlNGYxMFwiLFwiY2M0MDg3OWNhYjFjYTk3OGE2MjQxZWYwNDFkODg0MmZcIixcIjYyMjhhZGZiMDUwMTVkZjA5ZjlmN2ZlNDQ4NGE3ZjhhXCIsXCI4OGE2NDBhZWJmOGIwMjNhMmNlMDhmYzEzZjgzYTZkNVwiXSxcIjM5XCI6W1wiNmNjN2U2MDgxMGIwNDEzYTBiM2NkYzQzYjAxZGYxMmJcIixcImQwNWVlODFiZTg1MDAyYTA4YzgxYTE0NDJiY2YxODgxXCJdfSIsImY0NGZhMTk4ZjQ4YjQyYWVhYThiMmM5NTlkODQ5YjYwIl0=' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_1' id='gform_source_page_number_1' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"ak_\"><label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"ak_js\" value=\"76\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><input type=\"hidden\" name=\"trp-form-language\" value=\"en\"\/><\/form>\n                        <\/div><script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 1, 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